ENROLLMENT HISTORY - School District of Philadelphia

SCHOOL DISTRICT OF PHILADELPHIA

STUDENT REGISTRATION FORM (EH-40) PARENT / GUARDIAN MUST COMPLETE THIS FORM AND PROVIDE ALL NECESSARY DOCUMENTS

Please Print All

STUDENT INFORMATION - SECTION 1

Last Name

First Name

M.I.

MONTH

Date of Birth

DAY

YEAR

STUDENT ID NUMBER

House No.

Dir

Street Name

St., Ave., Etc.

Apt# Zip Code Phone Number

Race Designation: Is this student Hispanic Yes or No Gender: Male / Female

Check all races that apply: InWfohrimteatioBnlack / African American

Native Hawaiian / Other Pacific Islander

Country of Birth: Home Primary Language Date child first enrolled into a U.S. School

Asian American Indian / Alaska Native

STUDENT ENROLLMENT HISTORY - SECTION 2

Indicate city and type of school child last attended

Philadelphia

Other City:

Public School Non Public School

Date Last Attended Grade Last Attended Name of School Address

City

State

If the student attended school outside of the United States, do you have his/her school records?

Yes:

If yes, please provide a copy for the school __________________________________________________________

No:

If no, please contact the school to obtain the records __________________________________________________

Did the child ever attend: Pre-Kindergarten and/or Kindergarten

1) Has the child ever received Special Education Services in PA or another state? Yes No

2) Does your child have a current IEP?

Yes No

3) Does your child have a current evaluation report?

Yes No

4) Was the child ever enrolled in an Early Intervention Program?

Yes No

5) Has the child ever received ESOL/Bilingual services?

Yes No

6) Does your child have a 504

Yes No

7) Does your child have a Gifted IEP?

Yes No

LANGUAGE SURVEY - SECTION 3

English

1) What language does the family speak at home most of the time?

2) What language does the parent(s) speak to her/his child most of the time?

3) What language does the child speak to her / his parent(s) most of the time?*

4) What language does the child speak to her/his brothers/sisters most of the time?*

5)) What language does the child speak to her/his friends most of the time?*

6) What language does the child speak most frequently?*

If yes, which state: If yes, what If yes, which state:

Other

Language

7) What other languages does the child speak? 1) _____________________ 2) ____________________ 3) ____________________

* If the answer to these questions is other than English, the student must be given the English placement test (W-APT) by a certified administrator.

SCHOOL DISTRICT OF PHILADELPHIA

STUDENT REGISTRATION FORM (EH-40) PARENT / GUARDIAN MUST COMPLETE THIS FORM AND PROVIDE ALL NECESSARY DOCUMENTS

HOUSEHOLD INFORMATION - SECTION 4

Student Resides With:

Both Parents (same address )

Mother

Parent / Guardian Name:

Father

Stepparent

Parent / Guardian Name:

Guardian / Other

(Circle) Mother / Father / Stepparent / Guardian / Other

(Circle) Male / Female

[Active Military] Yes / No

Address:

(Circle) Mother / Father / Stepparent / Guardian / Other

(Circle) Male / Female

[Active Military] Yes / No

e

Address:

Phone: (Home)

(Cell)

(Work)

Phone: (Home)

(Cell) (Work)

Email:

Email:

date:

Preferred Language for School Related Communications:

Preferred Language for School Related Communications:

MCKINNEY-VENTO ELIGIBILITY - SECTION 4 (continued) (THIS INFORMATION WILL BE KEPT CONFIDENTIAL)

Please indicate your current housing status: Rent Lease Own

In a motel/hotel due to loss of housing, economic hardship or similar reason Are you currently living with a family member due to loss of housing, economic hardship or similar reason Did you experience a man-made disaster/fire Did you experience an eviction If the family is eligible for the Homeless Assistance Act of 1987 (known as McKinney?Vento) please contact your school counselor once registration is completed.

SIBLING INFORMATION - SECTION 5

Please list all school aged children (ages 5 and above)

Name

D.O.B.

Current School

Grade Student ID# if available

EMERGENCY CONTACT INFORMATION - SECTION 6 * Please list two LOCAL emergency contacts and their relationship to the child in the event a parent or guardian cannot be reached: Primary

1)

Name

Relationship

Gender: Male / Female

Phone (1)

Secondary 2)

Name

Phone (2) Relationship

Gender: Male / Female

Phone (1)

Phone (2)

By signing below, I am allowing the School District of Philadelphia to register my child as a student. I also certify the information provided on this

application to be true and accurate and providing false or incomplete information that is required for registration may delay enrollment.

Parent / Guardian Signature

Date

Parent / Guardian Signature

Date

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